VA unit downplayed complaints in psychiatric unit

U.S. Rep. Robert C. "Bobby" Scott, D- Newport News, talks with the media after a tour of the Hampton Veterans Affairs Medical Center. His visit was prompted by the death of veteran Floyd Washabaugh.

The psychiatric ward at the Hampton Veterans Affairs Medical Center neglected physical problems in at least two cases.

By admitting themselves to the psychiatric unit at the Hampton Veterans Affairs Medical Center, Floyd "Chip" Washabaugh and Glen Brennan were asking for help.Washabaugh, a 63-year-old combat veteran wounded in Vietnam, was suffering from depression. He didn't want to commit suicide, he told physicians, but was convinced that he would soon die.

Brennan, a 35-year-old husband and new father, wanted to kick a drug addiction that he'd fought for several years.

Both men died at the VA hospital after frequent complaints of physical pains: Washabaugh was often short of breath, and Brennan had back pain -- later determined to be from a fractured vertebra.

Their complaints were largely ignored by the staff, according to Washabaugh's medical record and a malpractice lawsuit filed by Brennan's widow.

Their deaths, a physician and three nurses familiar with the unit told the Daily Press, aren't anomalies. They are part of a pattern of mental health patients not receiving treatment -- or receiving the wrong treatment -- for physical problems.

"There is a callous disregard for medical issues of patients on the unit," said the doctor, who asked not to be named. "The unit is the most dangerous place to be at the VA."

When Washabaugh complained of trouble breathing, a doctor in the unit prescribed Washabaugh an anti- anxiety medication.

The unit's medical staff decided that Brennan's complaints of back pain were an attempt to get drugs, according to his widow's lawsuit. He died in 2001 of a drug overdose, which his family thinks was his way of self-medicating.

This year, the hospital paid $210,000 to settle the lawsuit and acknowledged that it was responsible for Brennan's death.

A spokeswoman for the hospital said there had been three deaths in the unit in the last 10 years. "That is very minimal in a 10-year span of time," said Wanda Mims, director of the Hampton medical center.

But that number doesn't include patients, such as Washabaugh, who got sick in the unit and then died after being transferred to the intensive care unit or the emergency room.

The Daily Press asked two weeks ago how many patients from the unit have died after being transferred to the ICU or the ER, but the hospital has yet to provide that information, saying it would require extensive research.

Mims said each death was taken seriously.

"We're all about providing quality care," she said. "Are we perfect? No. No institution is perfect. But we do have systems in place to identify (problems) to ensure we are addressing issues. We're here to provide great care to our patients."

The Joint Commission on Accreditation of Healthcare Organizations, which accredits the Hampton VA, requires hospitals to review any deaths considered unexpected, and its guidelines "encourage" hospitals to submit reports about those deaths.

Submitting the reports, the commission says, sends a "message to the public that (the organization) is doing everything possible to ensure that such an event will not happen again."

It also allows hospitals to learn from one another's experiences.

The VA hospital didn't report the deaths of Washabaugh and Brennan to the commission, though the information is available if the commission requests it.

Leigh Starr is the medical center's chief of quality management. She said that all deaths at the medical center were reviewed and that any deaths considered unexpected -- such as Brennan's and Washabaugh's -- received an immediate peer review to evaluate the medical care.

She said VA staff also conducted a "root-cause analysis" -- a study of whether systems broke down to lead to a death.

In a letter to Virginia Sen. Jim Webb, Mims wrote, "A clinical review of the circumstances of the case of Mr. Washabaugh was conducted, and based on this assessment, we feel confident that the highest patient care was provided in a timely manner."

Some current and former psychiatric unit staff members -- both nurses and doctors -- say the Hampton VA has done little to ensure that patients' complaints about physical problems aren't merely dismissed.

Instead, the unit's policies and procedures perpetuate that culture, the staff members said.

It was only recently -- after a Daily Press investigation led to pressure from Webb -- that one such policy was rescinded.

Until last month, no patients in the unit were allowed to have visitors -- a policy put in place in late 2004 that Dr. Priscilla Hankins, the hospital's chief of mental health services, said was a response to Brennan's death in 2001.

But the doctor with knowledge of the unit said, "Wives are the most valuable asset on picking up on medical problems. (Washabaugh) very well may have lived if he got prompt medical attention."

VA officials say medical attention for patients in the unit starts when they are admitted.

Patients must be physically examined and their medical histories recorded before they arrive in the unit, Hankins said.

The unit is authorized to hold 60 patients at a time and is divided into two wards: acute and sub-acute. Patients are admitted into the acute ward.

Hankins said most of the patients arriving in the acute ward are suicidal, severely psychotic, depressed, confused, combative or going through detoxification from drugs or alcohol.

After patients are stabilized and have completed an initial phase of treatment, they're transferred to the subacute ward.

Nurses and doctors in the entire unit are supposed to monitor patients' physical well-being, as well as their mental struggles.

Specialists can be called to the unit to meet patients with suspected problems, Hankins said, and patients can be transferred to the emergency room or intensive care unit if they get into any acute distress.

"That's just standard patient care," Mims said. "When a need arises to transfer a patient to a more acute setting, whether that be the ER or ICU, that's what we do. That's what the nurses are required to do. That's what the docs are required to do, as necessary."

In the meantime, patients' vital signs -- temperature, blood pressure and pulse -- should be taken at least daily, Hankins said. The medical center's protocol calls for vital signs to be recorded in each patient's medical record.

A nurse who used to work on the unit -- and who asked not to be named -- said that didn't always happen.

"If a patient was sleeping, nurses won't take the vitals," the nurse said.

Based on the number of times that vital signs were recorded in Washabaugh's medical record -- including on the morning he died and the physical exam done when he was admitted -- medical staff took his vital signs five times. He was on the unit for 13 days.

During that two-week period, Washabaugh frequently complained of shortness of breath.

According to his medical records, it wasn't until the last few hours of his life that anyone measured the oxygen saturation level in his blood.

That measurement is done with a pulse oximeter -- a small clip that goes on a finger and shines a laser into the nail bed.

"If somebody told me they were feverish, I would take their temperature," said Dr. John Perry, a pulmonary specialist with Peninsula Pulmonary Associates in Newport News. "If they tell me they're short of breath, I check their blood oxygen level."

Audrey Moore, the medical center's assistant director of patient care, said pulse oxygen readings were taken as needed. When a patient is having a hard time breathing or complains of shortness of breath, Moore said, a reading should be done.

There are several pulse oximeters in the unit, Hankins said.

According to his medical records, when Washabaugh complained that he was having trouble breathing, he was given Ativan, an anti-anxiety medication -- even on the morning he died, when his difficulty breathing didn't subside for hours.

The nurse that morning gave Washabaugh a "paper bag to breathe in ... cold cloth to his forehead."

That was the wrong response. According to Perry, the paper bag technique -- typically used for someone hyperventilating -- further reduces the oxygen that someone breathes in.

About 20 minutes later, Washabaugh again complained that he was having trouble breathing.

A pulse oximeter reading -- the first since he'd started complaining of shortness of breath -- was 88. The normal range is between 95 and 100.

Perry said a reading as low as 88 was "never a normal number. Something certainly is causing it.

"Would you know it's a blood clot? Not necessarily. It could be heart failure, a collapsed lung. But it should prompt some kind of evaluation."

Washabaugh's nurse wrote that she referred him to the doctor and then the "patient (was) encouraged to relax."

At 8:55 a.m., Washabaugh was seen by a medical student who noted that "he denied chest pain ... but did feel anxious and somewhat short of breath. He was breathing more rapidly than normal."

Between 9:15 and 9:27 a.m., Washabaugh received a small dose of an anti-anxiety medication.

According to the doctor's notes, Washabaugh's "pulse ox at this time revealed a reading of 85."

A nurse wrote that she "wheeled patient to a quiet area and attempted to direct patient to breathe through his nose and out through his mouth. Patient was able to slow his breathing down a little but would start breathing fast again. His facial color was pale at first, then he regained color."

About 9:30 a.m., Washabaugh asked to be wheeled back to the nurses station. His pulse ox dropped to 59.

Washabaugh was taken to the intensive care unit and pronounced dead at 10:35 a.m. Cause of death: massive pulmonary embolism, or blood clot in his lungs.

His autopsy report revealed that in addition to the massive clot, there were several patches of dead tissue in his lungs.

"Usually -- and 'usually' is the key word -- that means he's had several smaller emboli (blood clots) and that those areas of (dead lung) were happening before the major clot that came," Perry said.

Essentially, each time when Washabaugh complained of shortness of breath in the days before his death could have been when those smaller blood clots were hitting the lung.

Pulmonary embolisms are the third-leading cause of death in hospitals.

Long periods of inactivity can lead to a blood clot.

It's why doctors encourage patients to get up and move around as soon as possible after surgery and why family physicians have long been telling patients to frequently get up and walk around during long plane rides.

Washabaugh's records are littered with reports that he was only "out of bed for dinner and a phone call" or "patient has been sitting in bed for long periods."

Before Washabaugh was transferred to Hampton from another VA hospital, his wife, Nancy, frequently visited him and made a point of getting him up and walking around.

The medical staff in Hampton wouldn't let her see her husband.

In the two weeks when Washabaugh was in the unit, Nancy was allowed to see him only once -- for a treatment consultation -- before she received a phone call from the hospital, telling her that her husband was dead.

Jan Garrity is a retired Navy commander who served as a combat-stress nurse. She described another problem in the unit:

Garrity used to teach a nursing course at a local university. She brought her students to the unit for clinical work and said she immediately noticed that if it weren't for her students and the hospital chaplains, the patients would have little to no interaction with the unit's staff.

"There wasn't any programming on that unit to get the patients up and moving or to help heal them holistically," Garrity said. There were group meetings in the morning and in the evening, but nothing in between, she said.